Consultation on CQC S New Approach To

Draft version 2.18–14.06.13 - RESTRICTED

A new start

Consultation on changes to the way CQCregulates, inspects and monitorscare services

The Care Quality Commission is the independent regulator of health and adult social care in England.

Our purpose:

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

Our role:

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find, including performance ratings to help people choose care.

Our principles

• We put people who use services at the centre of our work
• We are independent, rigorous, fair and consistent
• We have an open and accessible culture
• We work in partnership across the health and social care system
• We are committed to being a high performing organisation and apply the same standards of continuous improvement to ourselves that we expect of others
• We promote equality, diversity and human rights

Foreword – from Chair and Chief Executive

• In April this year our new strategy, Raising standards, putting people first, set out a clear purpose for CQC - to make sure health and social care services provide people with safe, effective, compassionate, high-quality care and to encourage care services to improve.

• To deliver our purpose, we are makingsignificant changes to how we work.Most importantly, we are acting on the recommendations of thereport into the abuse of people with learning disabilities at Winterbourne View, of Robert Francis’ report into the failings at Mid Staffordshire NHS Foundation Trust and the government’s response to those catastrophic failures of care in ‘Patients First and Foremost’.
• We have listened to independent reviews such as Professor Kieran Walshe’s evaluation of our work,Deloitte’s report on how we carry out investigations and Grant Thornton’s review of our regulatory activity at University Hospitals of Morecambe Bay NHS Foundation Trust. The way the health and social care system is organised now makes it even more important that we work better with others.
• This consultation is an important next step towards making the changes needed to deliver our purpose. It sets out the principles underlying how CQCwill inspect all services and some more detailed proposals for how we will inspect NHS trusts and foundation trusts and independent acute hospitals. It also includes some joint proposals between CQC and the Department of Health on changes to regulations that underpin our work, including some important new responsibilities for CQC set out in the Care Bill. This is the beginning of a series of consultations on detailed changes to how different types of services will be inspected, with changes being implemented at different times during the next three years.
• We approach this work with humility, recognising that the main responsibility for delivering quality care lies with care professionals, clinical staff, providers, and those who arrange and fund local services.However, we are clear that we will expose services providing mediocre and inadequate care and we will have zero tolerance for services where people are failed on the most fundamental aspects of care. At the other end of the spectrum we will acknowledge and highlight the many hospitals, care homes and other services in England where people are receiving good or outstanding care.
• The intention is to develop the CQC into a strong, independent, expert inspectorate whose evidence-based, professional judgements are welcomed and instructive. How Ofsted approach their work is valued and we will learn from that. We will expect services to be open and honest about any problems they have. If there is a willingness to take responsibility for putting them right, we will take this into account in our response.
• Above all, we will always be on the side of people who use services, making sure that they are treated with respect and that their views and experiences of care are listened to and acted on.We will be independent of, but not distant from, our partners in the health and social care system.We will work closely with Healthwatch England to ensure we develop our new approach with people who use services.
• We will inspect and regulate different services in different ways based on what has the most impact on the quality of people’s care. However, there are some principles that will guide our work:
• When we inspect we will ask the following questions about care services:
• Are they safe?
• Are they effective?
• Are they caring?
• Are they responsive to people’s needs?
• Are they well-led?
• We will agree clear standards of care that helpus judge the quality and safety of services. They will include, but are notlimited to, the fundamentalsof care recommended by Robert Francis below which no provider must fall without facing serious consequences.We will work with NICEto ensure these align with their quality standards and so provide a comprehensive spectrum of standards, as recommended by Robert Francis.
• We will use surveillance of information and evidence to decide when, where and what to inspect, including listening better to people’s experiences of care and using the best intelligence from across the system.
• Our inspectors will no longer be generalists who inspect all types of care services. We are now appointing powerful and respected Chief Inspectors of Hospitals, Social Care and General Practice to lead national teams of expert inspectors.The teams will include clinical and other experts, including people with experience of receiving care. We will spend longer inspecting NHS hospitals, including in the evenings and weekends when we know people can experience poorer care.
• Our expert inspectors will no longer make statements simply about compliance with standards. They will use professional judgement, supported by objective measures and evidence to assess the quality of services against our five key questions. This will include a rating to help people compare services and to highlight where care is good or outstanding and expose where care is inadequate or requires improvement.
• Our Chief Inspectors will use the expert judgements of their teams of inspectors, together with information and evidence held by CQC and our partners in the system, to provide a single, authoritative assessment of the quality and safety of care services.
• We will make sure that directors or leaders of organisations make a legal commitment to provide safe, high quality care and are personally held to account for it
• In NHS hospitals, we will introduce a clear programmefor hospitals that are failing to provide quality care that makes sure that immediate action is taken to protect people and to hold those responsible to account.

• Some of the changes will take up to three years to make. We are grateful for the support of our partners and colleagues across the system in recognising our need to prioritise these, so thatthe changes to the way we inspect NHS and independent acute hospitalswill be introduced first. We welcome their continued support as we begin our dialogue with our colleagues in the other sectors.We will hold formal consultations with thesesectors, starting with adult social care in autumn 2013.

• We will take account of the emerging thinking from other reviews and initiatives, including Don Berwick’s task force looking at safety in the NHS, Camilla Cavendish’s investigation into the non-professional care workforce in health and social care, and the review of complaints by Professor Tricia Hart and Ann Clwyd MP.

• Following the government’s response to the failings at Winterbourne View,we are also making some immediate changes for those services caringfor people with learning disabilities. We know that there are continuing problems with the quality of care for people with learning disabilities, including lengthy stays in hospital for people away from their families and communities. We will also work with experts in the field to develop a way of inspecting those services that includes looking at whether the right services are being commissioned.

• Over the past year we have developed these changes inconversation with the public, our staff, providers, organisations with an interest in our work,clinical and other experts and our partners in the health and social care system andthis consultation is a continuation of those valuable discussions.We hope as many people as possible will give us their views and comments. We want to make sure these changes are the right ones and that they help us to deliver our purpose - to make sure health and social care services provide people with safe, effective, compassionate, high quality care.

David PriorDavid Behan

ChairChief Executive

Section 1

Introduction

• This document asks what you think of our proposals to make significant changes to the way we inspect and regulate health and social care. It is the first of a series of consultations we will hold between now and 2016 as we develop and introduce differentchanges for different types of services.
• We are committed to developing them in partnership with the public, people who use services, our staff, our partners in the system, experts, providers, and organisations with an interest in our work and we have an extensive programme of engagement planned to do this.
• Our proposed timescales for introducing the changes are set out below.
• Section 2 of this document setsout the principles for our inspection and regulation of all care services. It applies to everyone we regulate. It includes

• a better registration system for those applying to offer new care services, including holding senior managers, Boards and Directors of services to account for poor quality care
• intelligent monitoring ofinformation and evidence to decide when, where and what to inspect, including listening better to people’s experiences of care
• improvements to how we will inspect services, including the introduction of Chief Inspectors to lead expert teams
• clear standards of careincluding, but not limited to,the fundamentals of care below which no provider must fall
• a ratings system to help people choose between services and to encourage improvement
• the action we will take in response to poor care

• Section 3 sets out more details on a new way of inspecting and regulating NHS and independent acute hospitals, including
• the indicators that we will use to trigger action in our monitoring of information and evidence aboutacute hospitals
• longer, more thorough hospital inspections where required
• a clear programme for failing hospitals that makes sure immediate action is taken to protect people and to hold those responsible to account
• how we will issue and review ratings for acute hospitals

• Section 4 sets outproposals forchanges to regulations made by the Department of Health and CQC whichunderpin our current proposals. This section of the consultation applies to all providers registered with us.
• Section 5 repeats the consultation questions that we are asking throughout this document
• Finally, this document is accompanied by:
• a draftEquality and Human Rights Duties Impact Analysis– which gives more detail about the impact of the proposed changes on equality and human rights and how they willpromoteequality andhuman rightsfor people who use health and social care services
• a draft Regulatory Impact assessment - which outlines the costs and benefits to providers and people who use services.

Both of these impact assessments will be updated and published as final versions when we publish our response to this consultation.

When we will introduce the changes

• In June 2013 the Department of Health will consult on plans to strengthen corporate accountability in the wake of events at Winterbourne View hospital.
• From July 2013 we will build on the commitments we made in the government’s response to the failures at Winterbourne view and make sure that named directors, managers and leaders of services for people with learning disabilities commit to meeting our standards and are held to account for it.

• From October 2013, we will begin to change the way we inspect NHS and independent acute hospitals, because we recognise there is an urgent need to improve how we do this.The new Chief Inspector will spearhead a more specialist, expert and risk-based approach to inspection.
• We will award a rating for a hospital once we have inspected it under the new approach. As we do not yet have the legal powers to award ratings, our initial ratings will be in shadow form, and they will be confirmedsubject to the passage of legislation through Parliament.
• We will also begin to develop changes to the way we inspect other services, prioritising those where people are in the most vulnerable circumstances and where there are higher risks to people.
• In 2014/15 we will introduce changes to the way we inspect all services for people with learning disabilities and mental health issues provided by NHS trusts and independent healthcare providers.
• Also in 2014/15 we will begin to change the way we inspect adult social care services, including introducingratings.We will run the first of our consultations for adult social care in autumn 2013which will set out our initial thinking on how we will change our regulatory approach for this sector.
• Over the next two years we will review and develop changes to the way we inspect other services, including those who provide GP, out of hours and dental services. Our Chief Inspector of General Practice will lead this work, including the development of ratings for providers of GP services.This year we will run the first of our consultations for General Practice which will set out our initial thinking on our new regulatory approach. We have not yet decided whether we will rate services such as dental practices andthose that provide cosmetic surgery.
• In 2015/16we will make changes to our inspection of community healthcare and ambulance trusts, including introducing ratings.

What’s changing?

Section 2

How we will inspect and regulate care services

• We will inspect and regulate different services in different ways based on what has the most impact on the quality of people’s care. However, there are some general principles that will guideour future ‘operating model’. They apply to:the way we register thosethat apply to CQC to provide care services;the standards that those services have to meet; how we use data, evidence and information to monitor services; the expert inspections we carry out; the information we provide to the public on our judgements about care quality, including a rating to help people compare services;the action we take to require improvements and, where necessary,the action we take to make sure those responsible for poor care are held accountable for it.
• Figure 1: Overview of our future operating model.

Asking the right questions about the quality and safety of care

To get to the heart of people’s experience of care, we need to make sure we ask the right questions about the quality of services, based on the things that matter to people. We will ask the following five questions of every service:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

We developed these five questions with reference to the areas that Lord Darzi defined as central to quality in healthcare: safety, clinical effectiveness and the experience of people who use services. The first two of these linkdirectly to our key questions: whether a service is safe and effective. However, because we regulate social care as well as health services, our approach to assessing effectiveness will be broader than clinical effectiveness.

We have separated the experience of people who use services into two parts: how caring a service is and how responsive it is to meeting people’s needs.And although leadership, governance and culture has not been a formal element of our existing approach, our experience has shown that these factors make the difference between success and failure.

We will develop guidance on what we will focus on when we carry out an inspection to provide a judgement in relation to all of the five key areas,working with our strategic partners and drawing on developments and emerging thinking from the field. We will consult publicly on the guidance we develop, including how we will focus the new approach to providing a judgement on the five questions for different sectors to make sure it is relevant and tailored appropriately.

What do we mean by these five questions?

By safe, we mean that people are protected from physical, psychological or emotional harm. For example, are people getting MRSA (a hospital-acquired infection) because of poor hygiene?

In our approach to safety, we have been consulting Don Berwick’s task force on achieving zero harm and talking to the Health Foundation about their research into measuring and monitoring safety,with a view to working with them to develop our approach to measuring and monitoring safety, leadership and culture.